Identifying and meeting the needs of maltreated children with mental health problems

This research addresses three topics related to improving child welfare and mental health services for children involved with child welfare: need, identification, and service-symptom relationships. Each study in this series uses data from the National Survey of Child and Adolescent Well-being (NSCAW), the first nationally-representative sample of children investigated for maltreatment. Results show that 62% of children experience clinical-level emotional-behavioral problems at some point over three years following a maltreatment investigation. One-fifth of children report clinical-level depression and 19% report clinical-level post-traumatic stress. Thought and attention problems are among the most prevalent and persistent types of problems reported by children's caregivers, as are externalizing behavior problems. Children appear to experience heightened symptoms at the time of the investigation, but also experience symptom discontinuity over time, suggesting the need for services that target multiple symptom-areas. At least 470,000 children nationally may not be recognized by child welfare workers as having mental health symptoms at the conclusion of a maltreatment investigation, according to this research. Using risk assessment and investigative information to identify children with symptoms correctly classifies 75 to 80% of children and therefore could serve as a first-level screen. This would reduce the number of children who are provided a standardized psychological measure, having the potential for benefit and cost-avoidance. Analysis of the relationship between mental health services and changes in children's symptoms over time failed to demonstrate a positive service-symptom relationship. That is, children who receive mental health services have significantly higher levels of symptoms compared with children who do not receive services. Children typically receive school-based counseling services and less often receive in-home counseling, suggesting the need for more family-focused approaches to their mental health. Children may receive services prompted by their "acting-out" behaviors, at the same time that their family is experiencing substantial problems. This may give children the message that their behavior is the primary problem rather than the family circumstances that led to their child welfare involvement. Clearly, maltreatment is associated with mental health problems, and our current state of knowledge and practice appears insufficient to make measurable differences in children's level of risk for such problems

Development and Initial Findings of an Implementation Process Measure for Child Welfare System Change

This article describes a new measure designed to examine the process of implementation of child welfare systems change. The measure was developed to document the status of the interventions and strategies that are being implemented and the drivers that are being installed to achieve sustainable changes in systems. The measure was used in a Children’s Bureau-supported national effort to assess the ongoing implementation of 24 systems-change projects in child welfare jurisdictions across the country. The article describes the process for measure development, method of administration and data collection, and quantitative and qualitative findings

Case Reports1. A Late Presentation of Loeys-Dietz Syndrome: Beware of TGFβ Receptor Mutations in Benign Joint Hypermobility

Background: Thoracic aortic aneurysms (TAA) and dissections are not uncommon causes of sudden death in young adults. Loeys-Dietz syndrome (LDS) is a rare, recently described, autosomal dominant, connective tissue disease characterized by aggressive arterial aneurysms, resulting from mutations in the transforming growth factor beta (TGFβ) receptor genes TGFBR1 and TGFBR2. Mean age at death is 26.1 years, most often due to aortic dissection. We report an unusually late presentation of LDS, diagnosed following elective surgery in a female with a long history of joint hypermobility. Methods: A 51-year-old Caucasian lady complained of chest pain and headache following a dural leak from spinal anaesthesia for an elective ankle arthroscopy. CT scan and echocardiography demonstrated a dilated aortic root and significant aortic regurgitation. MRA demonstrated aortic tortuosity, an infrarenal aortic aneurysm and aneurysms in the left renal and right internal mammary arteries. She underwent aortic root repair and aortic valve replacement. She had a background of long-standing joint pains secondary to hypermobility, easy bruising, unusual fracture susceptibility and mild bronchiectasis. She had one healthy child age 32, after which she suffered a uterine prolapse. Examination revealed mild Marfanoid features. Uvula, skin and ophthalmological examination was normal. Results: Fibrillin-1 testing for Marfan syndrome (MFS) was negative. Detection of a c.1270G > C (p.Gly424Arg) TGFBR2 mutation confirmed the diagnosis of LDS. Losartan was started for vascular protection. Conclusions: LDS is a severe inherited vasculopathy that usually presents in childhood. It is characterized by aortic root dilatation and ascending aneurysms. There is a higher risk of aortic dissection compared with MFS. Clinical features overlap with MFS and Ehlers Danlos syndrome Type IV, but differentiating dysmorphogenic features include ocular hypertelorism, bifid uvula and cleft palate. Echocardiography and MRA or CT scanning from head to pelvis is recommended to establish the extent of vascular involvement. Management involves early surgical intervention, including early valve-sparing aortic root replacement, genetic counselling and close monitoring in pregnancy. Despite being caused by loss of function mutations in either TGFβ receptor, paradoxical activation of TGFβ signalling is seen, suggesting that TGFβ antagonism may confer disease modifying effects similar to those observed in MFS. TGFβ antagonism can be achieved with angiotensin antagonists, such as Losartan, which is able to delay aortic aneurysm development in preclinical models and in patients with MFS. Our case emphasizes the importance of timely recognition of vasculopathy syndromes in patients with hypermobility and the need for early surgical intervention. It also highlights their heterogeneity and the potential for late presentation. Disclosures: The authors have declared no conflicts of interes

Genomic epidemiology of SARS-CoV-2 in a UK university identifies dynamics of transmission

AbstractUnderstanding SARS-CoV-2 transmission in higher education settings is important to limit spread between students, and into at-risk populations. In this study, we sequenced 482 SARS-CoV-2 isolates from the University of Cambridge from 5 October to 6 December 2020. We perform a detailed phylogenetic comparison with 972 isolates from the surrounding community, complemented with epidemiological and contact tracing data, to determine transmission dynamics. We observe limited viral introductions into the university; the majority of student cases were linked to a single genetic cluster, likely following social gatherings at a venue outside the university. We identify considerable onward transmission associated with student accommodation and courses; this was effectively contained using local infection control measures and following a national lockdown. Transmission clusters were largely segregated within the university or the community. Our study highlights key determinants of SARS-CoV-2 transmission and effective interventions in a higher education setting that will inform public health policy during pandemics.</jats:p

School-age special education outcomes of infants and toddlers investigated for maltreatment

Examination of a nationally representative, longitudinal study of infants and toddlers investigated for maltreatment reveals disproportionate representation of teen mothers, fair/poor health, poverty, and being African-American. Infants are more likely to have special needs reported, subst`ance abusing caregivers, low-quality home environment, out-of-home placement, physical neglect, and substantiated maltreatment. At school-age, approximately one-fifth of all investigated infants and toddlers have an Individualized Education Program (IEP), indicating special education placement. Early characteristics associated with having an IEP include poverty, boys, fair/poor health, and low language scores. Hispanic children and those investigated for physical or sexual abuse were less likely to have an IEP. At school-age, infants had lower Woodcock-Johnson-III math subtests scores, whereas toddlers had lower reading comprehension performance.Infant and toddler maltreatment School-age special education placement Academic achievement

Directions for developmental screening in child welfare based on the ages and stages questionnaires

Many young children investigated for maltreatment have developmental problems qualifying them for early intervention services, yet only a portion of these children receive such services. To address this gap, all children ages 0-3 with child welfare (CW) substantiated maltreatment in Pennsylvania are screened for developmental and socioemotional problems using the Ages and Stages Questionnaires (ASQ). This study views screening results for over 500 children to address whether children's substantiation status, living situation, and administering worker as CW or early intervention (EI) predicts screening rates. Bivariate and logistic regression analyses were used. Results showed that 22% of children scored in the problem-range of at least one developmental area and 18% scored in the problem-range of social-emotional concerns warranting EI referral. Results of bivariate analyses showed that children who spent time in the NICU were more likely to have developmental concerns. Socioemotional concerns were related to child race, foster care living situation, child as the subject of the referral, and physical neglect. Older children and children whose referral involved lacking basic needs showed both developmental and socioemotional concerns. There were no significant differences in screening results of children with substantiated versus unsubstantiated maltreatment. Children whose screening was conducted by EI were more than three times as likely to show developmental concerns compared with those screened by CW. Child welfare workers need more support when conducting developmental screening, and policies that limit screening to children with substantiated maltreatment or to children in out-of-home care should be reconsidered.Developmental screening Screening Child welfare Early intervention Ages Stages questionnaires

Development and Initial Findings of an Implementation Process Measure for Child Welfare System Change

This article describes a new measure designed to examine the process of implementation of child welfare systems change. The measure was developed to document the status of the interventions and strategies that are being implemented and the drivers that are being installed to achieve sustainable changes in systems. The measure was used in a Children’s Bureau-supported national effort to assess the ongoing implementation of 24 systems-change projects in child welfare jurisdictions across the country. The article describes the process for measure development, method of administration and data collection, and quantitative and qualitative findings

Adverse Childhood Experiences and Complex Health Concerns among Child Welfare-involved Children

Adverse childhood experiences (ACEs) contribute to public health concerns, as they have been linked to chronic diseases in adulthood. From the seminal ACEs study in the mid-1990s (Felitti et al., 1998) to today, the Centers for Disease Control (2016) reports well over 50 studies that link ACEs to adult health conditions such as cancer, heart disease, lung disease, and mental illness. This preponderance of evidence has prompted widespread attention to the possibility that preventing and successfully treating ACE-associated traumatic stress would greatly reduce our country’s incidence of chronic disease and the associated public health burden and cost (Danese et al., 2009). To illustrate, one study suggests that child abuse and neglect alone costs the United States $124 billion annually, with individual lifetime costs that are higher than or equal to the economic burden of diabetes and stroke (Fang, Brown, Florence, & Mercy, 2012). That child maltreatment is just one category of 10 total ACEs suggests that the total financial impact of ACEs in the United States is likely much greater and that some populations, such as children involved in child welfare, may be disproportionately affected by the negative effects of adverse childhood experiences

Adverse Childhood Experiences and their Relationship to Complex Health Profiles among Child Welfare-involved Children: A Classification and Regression Tree Analysis

Objective To identify the clustering of adverse childhood experiences (ACEs) that best characterize child welfare–involved children with known complex health concerns. Data Source Multi‐informant data were obtained from Wave I of the National Survey of Child and Adolescent Well‐Being (NSCAW II). Study Design This study used a cross‐sectional design and classification and regression tree (CART) analyses. Data Collection Data were collected from families with children, aged birth to 17, investigated for child maltreatment and their child protective services caseworkers, including demographic characteristics of the children, their histories of adversity, and a wide range of health concerns. Principal Findings Results indicate that for children between the ages of six and 17, experiences of physical abuse alone, as well as experiences of physical abuse combined with having a caregiver with mental illness, are most strongly associated with complex health concerns. For children aged 2‐5 years, results suggest that caregiver mental illness is a key adverse experience associated with complex health concerns. Conclusions Identifying specific combinations of ACEs may be a critical next step for child‐ and youth‐serving agencies to allow providers to better calculate risk of health problems among children exposed to adversity

Adverse childhood experiences and resilience in childhood and adolescent and young adult cancer patients

Childhood and adolescent and young adult (AYA) cancer survivors experience poor health outcomes in adulthood. Adverse childhood experiences (ACEs) also portend poor health outcomes for the general population. Resilience can mitigate effects of ACEs. We examined the feasibility of assessing ACEs and resilience in childhood and AYA cancer patients. We also described occurrences of ACEs, resilience, and poor health outcomes. Of 52 participants, most rated their study experience favorably, with privacy in answering sensitive questions. Half reported ACEs, and those with ACEs had lower resilience; X2(3, N = 52) = 9.4, p = .02. Further investigations of ACEs and resilience in larger cohorts are warranted to delineate associations with long-term health outcomes